The developing world, and Sub- Saharan Africa in particular, is in many ways still in the asylum era, for those African countries with sufficient resources to sustain mental hospitals. For the others, life is still in the pre-asylum era, which on the surface appears to be full community care, but is in reality disregard of mental health care. The story of neglect of the asylums in Africa is legendary and the picture of malnourished psychotic often-chained patients is regularly interposed with a mosaic of hungry looking catatonic men and women wandering around the compounds of the mental hospitals, usually followed by equally tired looking demoralized poorly paid mental health professionals, marginalized from the rest of the medical fraternity by distance from the city center and low budgetary provisions. The poor state of mental hospitals in the developing world is an accurate reflection of the status accorded to the mental health needs of their communities.
Far behind the need to attend to high infant mortality, bacterial and parasitic infections and more recently AIDS, governments find justification in neglecting mental health needs on the mistaken belief that mental disorder does not cause significant mortality or morbidity. The World Health Report 2001 (1) underscores the impact of mental disorder on the global burden of disease. Few (if any) governments in the developing world seem able to factor this reality into the equation when providing mental health services.
The model proposed by Thornicroft and Tansella will therefore not work in the developing world until the fundamentals that lead to the neglect of mental health are attended to. Education of policy makers into the reality of the needs of those with mental disorder is a first and critical step.
Other seemingly peripheral issues to be addressed by Africans include poor governance, political instability, high social morbidity due to natural and manmade calamities (including wars), that give Africa some of the largest numbers of refugees per population in the world. All these factors conspire to give Africans some of the highest levels of independent risk factors for mental disorder of any continent. To complete the picture, facilities for research into the problems that arise are negligible (2). In spite of seeming to have the greatest need for research into their problems, Africans have extremely low activity in research. A recent survey of research in Sub-Saharan Africa could find only 1179 randomized controlled studies over the past 50 years! (2) Half of the trials were done in the relatively more developed South Africa, indicating the seriousness of the problem in the rest of Africa. Only 19 countries had more than one trial per million population. Neuropsychiatric conditions, the fifth most significant cause of disability as expressed in disability-adjusted life years (DALYs), were comparatively neglected, further emphasizing the plight of mental health needs.
Okasha (3) captured the plight of Africa most graphically, and listed some of the critical problems as being insufficient human and financial resources, absence of national mental health policies, shortage of specialized personnel, constant brain drain and widespread civil strife and violence as real and constant factors in the African scene. All these issues must be the subject of focus in the developing world even as one considers the model of balanced care proposed, as they have a bearing on its implementation as priorities continue to compete.
Most of Sub-Saharan Africa is listed by the World Bank Report 2002 (4) as existing below the poverty line, while the WHO World Health Report 2001 points to the relationship between poverty and mental disorder. To further complicate the picture, almost 80% of the countries in the same region spend less than 1% of the health budgets on mental health. (As an example, Kenya spends 7% of its annual budget on health and less than 1% of this on mental health!)
To contextualise Thornicroft and Tansella's discussion, Europe has an average 8.70 psychiatric beds per 10,000 population, while Africa has 0.34. To provide services, Europe has 9 psychiatrists per 100,000 population, while Africa has 0.05. Many African countries have no psychologists or social workers. Many healthy Africans have no employment and in some countries unemployment rates are as high as 50%. Schemes as proposed in Thornicroft and Tansella's paper intended to bring persons with mental illness to the labour market have to fight with this reality. In looking at the model of balanced care, the implementers of policy will have to decide on priorities at all levels, including questions on the critical numbers of mental health workers (psychiatrists, psychiatric nurses, psychologists, etc.) required to implement such services, and against the economic reality that most Africans survive on less than a dollar a day (4). Decisions have to be made on the best ways of spending the dollar, and specifically how much of it to give to mental health services.
The debate takes on a new dimension when psychiatrists are required to take a look at issues of national resource allocation as they affect the level of care given to their patients.
Frances Stuart (5), in an article on the root causes of conflict in developing countries, concludes that "the sharp economic and social difficulties between Western societies and the Muslim world are a clear example of international horizontal inequalities. These, together with widespread impoverishment in many Muslim countries, permit leaders such as Osama Bin Laden and Saddam Hussein to mobilize support only too effectively along religious lines". Whether one agrees with this view or not, it brings back to focus the fragile nature of peace, in this world, as well as the factors that maintain it (peace), and the relationship to health, since wars are a major cause of poverty and underdevelopment which themselves predispose to poor (mental) health. It seems as though one must keep looking further and wider.
These are the bleak facts. Is there reason to hope? Is there reason for optimism? The answer is a most emphatic yes to these questions.
One of the most pressing problems relates to poverty and governance as well as equity in the distribution of resources. The trend in Africa today (in spite of a few exceptions) is toward more open and transparent systems of governance, which should translate into more vibrant economies for the regions. This, coupled with the trend towards larger economic blocks in the regions, augurs well for Africans and their citizens with mental health needs. Serious efforts to study and anticipate civil strife in the continent are in evidence at both local and international levels. Nelson Mandela's activities in Burundi are a good example.
The developed world seems to be paying some attention to the developing world, following September 11, 2001 attack on New York, leading to the realization that inequality is a breeding ground for discontent, and there are signs that Western governments are committed to poverty eradication as one of the strategies of dealing with insecurity. In the long run, benefits could come to mental health, as evidenced by a number of ongoing projects on mental health policy support in Eastern Africa financed by the British Government with support by the World Health Organization.
Further reason for hope is homegrown. An example from Uganda illustrates a novel method of integrating the asylum and community approaches, similar though not the same as that proposed by Thornicroft and Tansella. Butabika Hospital has been transformed a few years ago from a traditional asylum to a beautiful modern institution, simply by making sure that it is adequately (and directly) funded, thus ensuring that patients receive medication and food. Many of the patients who previously stayed in the asylum for many years did so because they did not have adequate medication! With some of the funds saved by having fewer patients staying shorter, the hospital has been cleaned up and the patients given a cleaner, dignified environment in which to get better quickly and back to the community, giving even greater savings.
The community around Butabika has seen the improvement in the patients and the hospital, and are now happy to accept primary health care facilities from the asylum. The benefit to the war on stigma is great, as primary health care needs are satisfied in a former asylum where the local community is able to come face to face with formerly psychotic patients who are getting better.
There are three reasons to embrace Thornicroft and Tansella's approach. One because it is supported by common sense, secondly because there is evidence that community care works in spite of being perceived as a failure (6) and thirdly because increasing evidence supports the view that Sub- Saharan Africa is paying some attention to mental health, and as it does so must not make the mistakes made by the developed world in the asylum era. In this respect, Africa can and must avoid mistakes already made by the West, by applying its meagre resources to well thought out balanced care.
That the world is also paying attention to Africa is evidenced by the publication of this commentary in this official organ of the World Psychiatric Association, and one can only hope that the situation reported by Patel and Sumathipala (7), in which Africa hardly features in the leading journals of the world, will find resolution in the course of time. Africa has a great deal to teach and learn from the rest of the world. The future for Africa is good, the future of balanced care is assured as an appropriate model of care.
References
- 1.World Health Organization. World Health Report 2001. Mental health: new understanding, new hope. Geneva: World Health Organization; 2001. [Google Scholar]
- 2.Isaakidis P. Swingler G. Pienaar E, et al. Relationship between burden of disease and randomized evidence in Sub-Saharan Africa: survey of research. Br Med J. 2002;324:702. doi: 10.1136/bmj.324.7339.702. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Okasha A. Mental health in Africa: the role of WPA. World Psychiatry. 2002;1:32–35. [PMC free article] [PubMed] [Google Scholar]
- 4.World Bank. World Development Report 2002. Building institutions for markets. Washington: The World Bank; 2002. [Google Scholar]
- 5.Stuart F. Root causes of violent conflict in developing countries. Br Med J. 2002;324:342–345. doi: 10.1136/bmj.324.7333.342. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Leff J. Why is care in the community perceived as a failure? Br J Psychiatry. 2001;179:381–383. doi: 10.1192/bjp.179.5.381. [DOI] [PubMed] [Google Scholar]
- 7.Patel V. Sumathipala A. International representation in psychiatric literature. Survey of six leading journals. Br J Psychiatry. 2001;178:406–409. doi: 10.1192/bjp.178.5.406. [DOI] [PubMed] [Google Scholar]